MEDICARE: DR. SOH AGATSUMA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	25MA07729800	NJ

General Provider Information

NPI Number	:	1578778452
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SOH AGATSUMA M.D.

Provider Business Mailing Address
First Line	:	725 RIVER RD STE 202
Second Line	:
City	:	EDGEWATER
State	:	NJ
Zip	:	07020-1149
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	725 RIVER RD STE 202
Second Line	:
City	:	EDGEWATER
State	:	NJ
Zip	:	07020-1149
Country	:	US
Telephone Number	:	201-943-4040
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/13/2007
Last Update Date	:	07/08/2007

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